Traditional American Heart Association (AHA) training states that survival from cardiac arrest declines by 10% for every minute the brain goes without blood flow.(1) Although this is commonly used when discussing cardiac arrest without CPR, it’s also well recognized that traditional CPR provides less-than-adequate cerebral and cardiac perfusion.(2)

We report three patients within a 12-month period who survived out-of hospital cardiac arrest with no neurologic deficits despite an average of 30 minutes of CPR prior to return of spontaneous circulation (ROSC). The therapy during each resuscitation included implementation of 2005 AHA guidelines, early use of the ResQPOD impedance threshold device (ITD), use of a mechanical CPR device called LUCAS and therapeutic hypothermia using ice packs initiated by the first ALS providers.

These cases illustrate the success of multiple new therapies in cardiac arrest that together are improving the outcomes in victims of cardiac arrest, despite prolonged periods without spontaneous circulation.

Case #1A 72-year-old female with no previous cardiac disease became unresponsive while playing a card game. Family members immediately started CPR, which was taken over by police first responders on arrival. The ALS ambulance crew arrived five minutes after dispatch received the family’s call for help.

They continued with the resuscitation, which included immediate placement of ResQPOD, IV epinephrine and a LUCAS device. Further care included at least two defibrillations for ventricular fibrillation (V-fib) and medications, including amiodarone, vasopressin and epinephrine. After 25 minutes, the patient’s rhythm changed to bradycardia with a pulse. External cooling was initiated with ice packs on the groin, axilla and anterior neck.

The patient was transported by helicopter to a cardiac catheterization lab, where she underwent simultaneous therapeutic hypothermia via Arctic Sun and angiography with stenting of a lesion in her left anterior descending (LAD) artery.

She was discharged on hospital day 11. Her cerebral performance categories (CPC) score was 1.

Case #2
An 80-year-old male with a known history of severe cardiomyopathy, ejection fraction (EF) of 10–15% and coronary artery disease (CAD), including a previous stent in his right coronary artery, suffered a cardiac arrest in the car while his wife was driving him to the local hospital to be evaluated for weakness. On arrival at the hospital, he was brought into the emergency department (ED) and a LUCAS was placed. Other interventions included placement of an endotracheal (ET) tube, ResQPOD and medications, including epinephrine, vasopressin and amiodarone. His initial rhythm on arrival at the hospital was asystole with periods of V-fib that responded to defibrillation.

Throughout the 50-minute resuscitation, he was defibrillated six times and required intermittent CPR. Therapeutic hypothermia using an Arctic Sun unit was initiated prior to transport to a regional cardiac care center.

The patient’s angiogram showed no significant CAD. He remained in the hospital for 15 days and was discharged to a nursing home for treatment of nosocomial pneumonia with a CPC score of 1.

Case #3
A 68-year-old male suffered cardiac arrest in a movie theater. Bystanders initiated CPR, which was continued by first responders upon their arrival after confirming the patient had no pulse. Their AED advised them to defibrillate the patient one time, which they did and then continued CPR. ALS providers arrived 16 minutes after the patient collapsed. They placed an ET tube with an ITD. CPR was transitioned to a LUCAS.

Throughout the resuscitation, the monitor showed a slow, wide complex rhythm, likely of ventricular origin. He was given three 1 mg doses of epinephrine via IV and 50 mEq of sodium bicarbonate. The crew also attempted transcutaneous pacing. ROSC was identified 50 minutes after the initial call and maintained. Therapeutic hypothermia was initiated in the field using ice packs.

On arrival at the hospital, the patient had an emergent angiogram that showed no significant coronary artery blockages but an EF of 20%. An implantable cardiac defibrillator was placed.

He remained hospitalized for 21 days before being discharged with minimal cognitive deficits and a CPC score of 1.

Discussion
We report on these cases because of the length of time CPR was performed during the events. There’s some evidence that using mechanical CPR devices improves adherence to accepted CPR guidelines.(3) Although the survival of these patients can’t be attributed solely to the use of a mechanical CPR device, the device provided good cerebral perfusion throughout the arrest. For these reasons, we’ve deployed a LUCAS device in each of our 33 ALS ambulances since 2007. This addition has been an integral part of our success in treating cardiac arrest.

Conclusion
Survival from sudden cardiac arrest hasn’t improved in years. Recent advances in the care of these patients may lead to increased survival and good neurologic outcomes when implemented together. It may also lead to increased survival after prolonged cardiac arrest, contrary to past practice. These three cases do not define a medical breakthrough, but they indicate a need for further investigation of the use of ITDs, mechanical CPR and therapeutic hypothermia as complementary therapies in the care of cardiac arrest.

Disclosure: The authors have reported no conflicts of interest with the sponsor of this supplement.